Ivar Gladhaug MD
Specialist in Gastroenterological Surgery
Oslo University Hospital
Recently updated 04.05.2012
A Whipple procedure consists of three steps:
- The procedure is performed via an angled, epigastric transverse incision.
- The abdominal cavity is inspected and palpated thoroughly.
- Inoperability criteria are:
- liver metastasis
- peritoneal metastasis
- invasion of the base of the mesentery
- infiltration of the peritoneal surface
- growth into adjacent organs (not the duodenum)
- Kocherization is completed when the duodenum and head of the pancreas are dissected off the underlying structures.
- The hepatic artery and the base of the gastroduodenal artery are dissected and identified by vessel loops.
- The common bile duct is dissected and the area of division is identified with a vessel loop.
- The superior mesenteric vein is dissected at the lower edge of the pancreas.
- The lesser sac is divided and the omental bursa is opened, and the caudal edge of the pancreas is isolated.
- The portal vein is bluntly dissected behind the pancreas to isolate the portal vein. The dissected pancreas is identified with a vessel loop.
- The gastroduodenal artery is divided at the origin from the hepatic artery.
- The small intestine is divided 8–10 cm distal to the ligament of Treitz using a GIA stapler. This apparatus inserts two double rows of staples and divdes the tissue between them in one operation.
- The stomach is divided at the angulus, also with a GIA. The staple suture is inverted manually with sutures.
- A cholecystectomy is performed.
- The pancreas is divided with a knife between the head and body.
- The loop around the common bile duct is removed and the duct is divided.
- The tissue between the head of the pancreas and the portal vein and superior mesenteric artery is divided by dissection towards the vessels. The specimen is now free to be removed.
- The pancreas is anastomosed end-to-side to the distal small intestine with interrupted sutures.
- The common bile duct is anastomosed end-to-side further down on the small intestine. The anastomosis is performed with running sutures posteriorly and interrupted sutures anteriorly.
- The stomach is anastomosed side-to-side to the small bowel. The anastomosis is created with a GIA or with sutures. The opening from the GIA is closed with running sutures.
- The abdomen is flushed and a drain is placed in the anastomosis area.
- The abdominal wall is closed by two layers of running sutures. The skin is closed with staples.
- The surgical specimen is marked by the surgeon and sent to the pathologist.
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